Division of Mental Health Developmental Disabilities and Substance by jennyyingdi

VIEWS: 6 PAGES: 23

									              North Carolina Department of Health and Human Services
      Division of Mental Health, Developmental Disabilities and Substance Abuse Services
                    3008 Mail Service Center • Raleigh, North Carolina 27699-3008
                               Tel 919-733-0566 • Fax 919-715-3604
Michael F. Easley, Governor                                   Richard J. Visingardi, Ph.D, Director
Carmen Hooker Odom, Secretary


MEMORANDUM

TO:            Authorized NC DWI Providers

FROM:          Michael Eisen, Director of DWI Services
               Justice Systems Innovations Team
               Community Policy Management Section

RE:            DWI FACILITY QUALITY MANAGEMENT SURVEY

DATE:          December 3, 2003

First of all, holiday greetings and best wishes for the upcoming New Year! I have had the
opportunity to speak and meet with many of you over the last few months and sincerely
appreciate the feedback that has been provided. I will continue to welcome this dialogue.

Although this memo will be limited to a few pertinent time sensitive issues, I plan to keep
authorized DWI providers informed regarding ongoing areas of concern. On this note, please
contact this office with your email address if you have not done so already. This will be the
preferred method of communication.

On October 23, 2003, the Joint Legislative Oversight Committee on MH/DD/SAS studying DWI
Substance Abuse Services had their first meeting. Future meetings are scheduled for February
5, 2004 and March 11, 2004. Committee meetings are open to the pubic and you are
encouraged to attend. Feel free to contact me regarding information about the Committee
makeup and meeting times and locations. This study will include information on the type of
testing provided by an agency, the treatment offered by an agency, the average duration of a
program, the average cost of treatment, the rates of recidivism, and the adequacy of the fee
paid to the assessing agency by a client for a required substance abuse assessment. The
Committee must report its findings and any recommended legislation to the 2004 Regular
Session of the 2003 General Assembly.

You will find enclosed the DWI Facility Quality Management Survey, which will be utilized by
the Division in conducting the study of the Legislative Oversight Committee. This survey is a key
element of the study and will serve to assist the Division in improving access to care for DWI
offenders, increasing the quality and effectiveness of services, insuring best practices and
accountability of providers, and improving the safety of North Carolina communities. I strongly
encourage you to be honest and complete with your answers to the survey questions. It is
Page 2: Memo from Michael Eisen to Authorized NC DWI Providers

absolutely not our intention to use this Survey in a punitive manner. Please understand that
timely submission of this Survey by all authorized DWI facilities is a requirement of
DMH/DD/SAS facility authorization for provision of services to DWI offenders. The Survey is due
on Friday, December 19, 2003. We recognize that this is a tight timeline, but ask for your
cooperation and support.

To complement the information gathered on the surveys, we will also conduct informational site
visits with a small percentage of providers. The purpose of these visits is to: (1) follow up on the
data gathered in the surveys, (2) obtain in-depth feedback about opinions on raising the
assessment fee, and (3) collect information that will guide future technical assistance and
quality improvement efforts. Jennifer Resnick, DWI Services Quality Management Project
Consultant, may contact you in December or early January to schedule a site visit. Our hope is
to conduct these visits throughout the months of January and February of 2004.

The last item of this memo is in regard to DWI providers being contacted by staff from the
Regulatory Team of the Resource and Regulatory Management Section of the Division of
MH/DD/SAS. Based on the recent reorganization of the Division, the Regulatory Team is
responsible for provider monitoring and will be working collaboratively with the DWI Services
Office of the Justice Systems Innovations Team in their planning and conducting of monitoring
activities for the coming year. Initial telephone contact from Regulatory Team staff will begin in
December/January and monitoring site visits are planned to begin in March/April 2004. A
detailed letter will be sent to you prior to the site visits.

If you have any questions, please feel free to contact me at 919-733-0566 or email at
michael.eisen@ncmail.net. Thanking you in advance for your cooperation and providing a
valuable community service.


Enclosure (1)

Cc:     Executive Leadership Team
        Carol Duncan Clayton
        Dick Oliver
        Alice Lin
        Spencer Clark
        Sonya Brown
        Patrice Roesler
                                                                                                                            Date Survey Received
  Revised                                                                                                                      by Division of
Dec. 3, 2003                               NC Department of Health and Human Services                                          MH/DD/SAS:

                     Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

                                               Community Policy Management Section

                 Joint Legislative Oversight Committee on MH, DD, and SAS:
   DWI Facility Quality Management Survey of Substance Abuse Services to DWI Offenders -
                                          SFY 03-04
Statutory Authority: General Assembly of North Carolina Session Law 2003-396, Senate Bill 934
SECTION 2. The Joint Legislative Oversight Committee on Mental Health, Developmental Disabilities, and Substance Abuse Services
shall study the programs offered by assessing agencies to clients who must obtain a substance abuse assessment and a certification of
completion of a substance abuse program. The study should include information on the type of testing provided by an agency, the
treatment offered by an agency, the average duration of a program, the average cost of treatment, the rates of recidivism, and the
adequacy of the fee paid to the assessing agency by a client for a required substance abuse assessment. The Committee must report
its findings and any recommended legislation to the 2004 Regular Session of the 2003 General Assembly.

Instructions: Responses to the DWI Facility Quality Management Survey will be utilized by the Division in conducting the study of the
Legislative Oversight Committee. This study is intended to assist the Division in improving access to care for DWI offenders,
increasing the quality and effectiveness of services, insuring best practices and accountability of providers, and improving
the safety of North Carolina’s roads and communities. DWI services providers are encouraged to provide candid and complete
responses to this Survey. An electronic copy of this Survey is available upon request. Please complete and mail (preferred),
deliver, e-mail, or fax this DWI Facility Quality Management Survey for receipt by 5:00 p.m. on Friday, December 19, 2003 to:
                                                Daisy Adams, Quality Management Team,
                                       Community Policy Management Section, NC DMH/DD/SAS,
                                           3004 Mail Service Center, Raleigh, NC 27699-3004,
                              or Suite 634, Albemarle Building, 325 N. Salisbury Street, Raleigh, NC 27603,
                     Telephone (919) 733-0696          Fax (919) 715-2772          E-Mail: Daisy.Adams@ncmail.net

                                                           Address questions to:
                                Jennifer Resnick, DWI Services QM Project Consultant, at (919) 733-0696, or
                          Michael Eisen, Director of DWI Services, at (919) 733-0566, or Michael.Eisen@ncmail.net,
               or Spencer Clark, Director of Operations and Clinical Services, at (919) 733-4670, or Spencer.Clark@ncmail.net.

Timely submission of this Survey by all authorized DWI facilities is a requirement of DMH/DD/SAS facility authorization for provision of
services to DWI offenders.


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Page 2 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
                                                                                                                                Date Survey Received by
                                                                                                                                Division of MH/DD/SAS:
Section A:          Description of DWI Substance Abuse Services Facility

A-1.   Name of DFS Licensed Facility                                  A-2.   Name and Title of Facility Director or CEO
                                                                             (Facility’s Administrative Director responsible for facility compliance with
                                                                             DMH/DD/SAS Licensure Rules)



A-3.   Facility Location (Street Address, City, County, State, Zip)   A-4.   Name and Title of Facility Clinical Director (Qualified SA
                                                                             Professional: QSAP) (Facility’s Clinical Director responsible for
                                                                             oversight of assessment, treatment, supervision, and clinical records and
                                                                             practices)


A-5.   Mailing Address (PO Box or St., City, State, Zip)


A-6.   DMH/DD/SAS DWI Facility Code                   A-7.   Telephone No.(s)                          A-8.     Fax No.


A-9.   Name/Title of Staff Completing Survey          A-10. E-Mail Address (if available)              A-11. Web Site Address (if available)


A-12. Division of Facility Services Licensure Type(s) (Check          and complete for all DFS licenses held):

          .3500 Outpatient SA Treatment         __________________           ________________________________________________
                                                DFS License Expir. Date      Name(s) and Certification(s) of NCSAPCB Certified Counselor(s) Whose
                                                                             Services Are Available to Each Client Served by the Facility
          .3700 SA Day Treatment                __________________           ________________________________________________
                                                DFS License Expir. Date      Name(s) and Certification(s) of Each Fulltime NCSAPCB Certified
                                                                             Counselor in Day Treatment Facility for Every 16 or Fewer Clients
A-13. Type of DWI Facility (Check one):
         Public MH/DD/SAS Area Program or Local Managing Entity (LME)                      Private Not-for-Profit Agency

           Private For-Profit Agency                                                       Other (Describe)__________________________

A-14. Is facility accredited by a national accreditation group?                            Yes            No

If “Yes”, please list name of accreditation group:_____________________________________________________________________


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A-15.               Monday          Tuesday         Wednesday         Thursday              Friday            Saturday           Sunday
   Facility
  Operating
    Hours


A-16. Number of Full time Employees or Contracted Staff of Licensed Facility (Check              one):

          2 or Fewer Staff                 3 to 5 Staff                         6 to 10 Staff                       11 to 24 Staff

          25 to 50 Staff                   51 to 99 Staff                       100 to 199 Staff                    200 or More Staff


A-17. Number of Part-time Employees or Contracted Staff of Licensed Facility (Check               one):

          2 or Fewer Staff                 3 to 5 Staff                         6 to 10 Staff                       11 to 24 Staff

          25 to 50 Staff                   51 to 99 Staff                       100 to 199 Staff                    200 or More Staff



A-18. Description of Special Client Populations or Language or Cultural Groups that are targeted in your facility’s client
      outreach efforts and/or your provision of culturally competent services (Check or list all that apply):

          Severe Hearing Impairment               Other Physical Disabilities                   Concurrent Psychiatric Illness

          Spanish Speaking                        Other Communications Problem (List):___________________________________

          Other Language/Cultural Group (List) ____________________________________________________________________

          None of Above




Page 4 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
  Section B:                  DWI Substance Abuse Assessment Services and Fees


B-1.    Does your facility provide DWI Substance Abuse Assessment Services?                                   Yes                 No
        If “Yes”, complete remainder of questions in Section B and Section C. If “No”, skip to Section D.


B-2.    What is the Staff Assessor’s average direct service face-to-face time required with each client for the completion of a
        DWI Substance Abuse Assessment Service? (Check one)

             30 minutes or less                  31 to 45 minutes               46 to 60 minutes                    61 to 75 minutes

             76 to 90 minutes                     91 to 105 minutes             106 to 119 minutes                  2 Hours or more


B-3     What are the Division approved standardized test(s) utilized by your facility in the DWI SA Assessment?
        (Check or list all that apply)

      Substance Abuse/Life Circumstance Evaluation (SALCE)                      Substance Abuse Subtle Screening Inventory (SASSI)

      Court Procedures for Identifying Problem Drinkers (Mortimer-Filkens)      Driver Risk Inventory (DRI)

      Juvenile Automated Substance Abuse Evaluation (JASE)                      MacAndrew Alcoholism Scale (MAC) /Revised (MAC-R)

      Minnesota Assessment of Chemical Health (MACH)                            Personal Experience Screen Questionnaire (PESQ)

      Other (List):___________________________________________                  Other (List):__________________________________

      Other (List):___________________________________________                  Other (List):__________________________________




Page 5 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
B-4.   What is the estimated % of clients assessed in your facility that enroll in an ADETS within:
       (Include clients enrolled either at your facility or at another DWI facility)
                                                                  1 year of Assessment?    %

                                                           2 years of Assessment?           % (Include all enrolled within 1 yr.)

           Unable to provide estimate from existing program records and tracking system

B-5.   What is the estimated % of clients assessed in your facility that enroll in a Treatment Program within:
       (Include clients enrolled either at your facility or at another DWI facility)
                                                                  1 year of Assessment?     %

                                                           2 years of Assessment?           % (Include all enrolled within 1 yr.)

           Unable to provide estimate from existing program records and tracking system

B-6.   Does your facility require the DWI offender to pay a $50.00 standard fee for the DWI SA Assessment?           Yes      No
       If “Yes”, skip to B-8. If “No”, answer B-7.

B-7.   If “No”, what are the minimum, maximum, and average fees charged? $                 .00 $             .00 $              .00
                                           (Complete all three categories) Minimum                 Maximum            Average


B-8.   In your experience, how much of a barrier to timely services access does the current standard fee of $50.00 for a DWI
       SA Assessment present to the DWI Offender? (Check one)

          Extreme Barrier           High Barrier               Medium Barrier             Low Barrier         Not a Barrier


B-9.   What is the estimated actual cost to your facility, per assessed DWI offender, for the provision of the DWI SA
       Assessment Service?
                                                                                                                $             .00

Page 6 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
B-10. Provide a brief explanation of your facility’s method of computing the above estimated actual cost, per offender, for
      completion of the DWI Substance Abuse Assessment.




B-11. Do you favor a change in the current $50.00 standard fee that the DWI offender is required to pay to the assessing
      agency for the DWI Substance Abuse Assessment?
      If “Yes”, answer B-12, and skip B-13. If "No", skip B-12, and answer B-13.                                 Yes            No


B-12. If “Yes” above, what standard fee would you favor requiring the DWI offender to pay to the assessing agency for the
      DWI Substance Abuse Assessment?
                                                                                                         $           .00

B-13. If “No” above, why do you not favor a change in the current $50.00 standard fee that the DWI offender is required to pay
      to the assessing agency for the DWI Substance Abuse Assessment?




Page 7 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
B-14. In your view, how much of a barrier to services access would an increase in the current $50.00 standard DWI SA
      Assessment fee present to the DWI Offender? (Check one for each proposed fee amount)

a. Increase to $75 would be:               Extreme Barrier       High Barrier         Medium Barrier        Low Barrier            Not a Barrier

b. Increase to $100 would be:              Extreme Barrier       High Barrier         Medium Barrier        Low Barrier            Not a Barrier

c. Increase to $125 would be:              Extreme Barrier       High Barrier         Medium Barrier        Low Barrier            Not a Barrier


d. Increase to $150 would be:              Extreme Barrier       High Barrier         Medium Barrier        Low Barrier            Not a Barrier

e. Increase to $175 would be:              Extreme Barrier       High Barrier         Medium Barrier        Low Barrier            Not a Barrier

f. Increase to $200 would be:              Extreme Barrier       High Barrier         Medium Barrier        Low Barrier            Not a Barrier

g. Increase to over $200 would be:         Extreme Barrier       High Barrier         Medium Barrier        Low Barrier            Not a Barrier



Section C:             Qualifications of Staff Assessors Providing DWI Substance Abuse Assessment Services
Provide the following information for each Substance Abuse Services staff member who provides DWI Substance Abuse
Assessment Services in this facility. (For more than four staff, attach additional pages as necessary)
                                  _______________________      _______________________      _______________________       _______________________
                                   Name of Staff Member # 1     Name of Staff Member # 2     Name of Staff Member # 3      Name of Staff Member # 4
C-1.   What is staff member’s           Degree & Major               Degree & Major               Degree & Major                Degree & Major
       educational degree(s)         HS or GED                    HS or GED                    HS or GED                     HS or GED
       attained and major            Associate ___________        Associate ___________        Associate ___________         Associate ___________
       field(s) of study?
                                     Bachelor    ___________      Bachelor    ___________      Bachelor    ___________       Bachelor    ___________
       (Check and list all
       that apply)                   Masters     ___________      Masters     ___________      Masters     ___________       Masters     ___________
                                     Doctorate ___________        Doctorate ___________        Doctorate ___________         Doctorate ___________
C-2.   What is staff member’s
       total number of years of
       supervised experience
       in providing substance     Years:_________________      Years:_________________      Years:_________________       Years:_________________
       abuse counseling?



Page 8 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
Provide the following information for each Substance Abuse Services staff member who provides DWI Substance Abuse
Assessment Services in this facility. (For more than four staff, attach additional pages as necessary)
                                   _______________________     _______________________         _______________________        _______________________
                                    Name of Staff Member # 1    Name of Staff Member # 2        Name of Staff Member # 3       Name of Staff Member # 4
C-3.   Is staff member
       registered with the
                                       Yes           No             Yes             No             Yes             No              Yes            No
       NCSA Professional
       Certification Board?
C-4.   List staff member’s      Certification or Credential   Certification or Credential      Certification or Credential      Certification or Credential
       current NCSAPCB            CSAC                          CSAC                            CSAC                             CSAC
       Certification(s) or Other  CCAS                          CCAS                            CCAS                             CCAS
       Approved Credential(s).
                                  CCS                           CCS                             CCS                              CCS
       (Check all that apply)     CSARFD                        CSARFD                          CSARFD                           CSARFD
                                  Licensed MD                   Licensed MD                     Licensed MD                      Licensed MD
                                  Licensed Psychologist         Licensed Psychologist           Licensed Psychologist            Licensed Psychologist
                                  ASAM Diplomat                 ASAM Diplomat                   ASAM Diplomat                    ASAM Diplomat
C-5.   List languages (other      Spanish                       Spanish                         Spanish                          Spanish
       than English) that staff   American Sign Language        American Sign Language          American Sign Language           American Sign Language
       member speaks or
                                  Other: _______________        Other: _______________          Other: _______________           Other: _______________
       signs fluently.
       (Check all that apply)     Other: _______________        Other: _______________          Other: _______________           Other: _______________
C-6    What do you recommend should be North Carolina’s minimum education requirements for a facility staff member to provide DWI Substance Abuse
       Assessment Services? (Check one)          HS or GED       Associate (in related field)  Bachelor (in related field)   Masters (in related field)

C-7.   What do you recommend should be North Carolina’s minimum substance abuse certification requirements for a facility staff member to provide Substance
       Abuse Assessment Services? (Check one)          None          CSAC            CCAS



Section D:             Alcohol and Drug Education Traffic School (ADETS) Services and Fees


D-1.   Does your facility provide Alcohol and Drug Education Traffic School (ADETS) Services?                                    Yes             No
       If “Yes”, complete remainder of questions in Section D and Section E. If “No”, skip to Section F.




Page 9 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
D-2. ADETS          Monday          Tuesday         Wednesday         Thursday            Friday            Saturday                Sunday
  Schedule
  (List hours
  each day)

D-3.   Generally, in the past 12 months, what is the number of students in an ADETS group in your facility?

                          (Complete all three categories)               Min. No.            Avg. No.              Max. No.


D-4.   What do you recommend should be the maximum number of students in an ADETS group?                      Max. Recom. No.


D-5.   What is the estimated % of clients that enroll in ADETS in your facility that complete an ADETS Program within:
       (Include clients who complete either at your facility or at another DWI facility)

                                                            1 year of enrollment?           %

                                                            2 years of enrollment?          % (Include all enrolled within 1 yr.)
           Unable to provide estimate from existing program records and tracking system


D-6.   Describe the name of any manualized or evidence-based prevention education curriculum/curricula used in your
       facility’s ADETS.




D-7.   Does your facility require the DWI offender to pay a $75.00 standard fee for ADETS?                          Yes              No
       If “Yes”, skip to D-9. If “No”, answer D-8.



Page 10 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
D-8.   If “No”, what are the minimum, maximum, and average fees charged? $         .00           $           .00 $               .00
                                           (Complete all three categories) Minimum                Maximum            Average

D-9.   In your experience, how much of a barrier to timely services access does the current $75.00 standard fee for ADETS
       present to the DWI Offender? (Check one)
           Extreme Barrier         High Barrier               Medium Barrier          Low Barrier        Not a Barrier

D-10. What is the estimated actual cost to your facility, per student, for the provision of the 10 Hour ADETS Service?
                                                                                                         $           .00
D-11. Provide a brief explanation of your facility’s method of computing the above estimated actual cost, per student, for
      provision of the 10 Hour ADETS Service.




D-12. Do you favor a change in the current $75.00 standard fee that the DWI offender is required to pay to the ADETS facility
      for the ADETS Service?
      If “Yes”, answer D-13, and skip D-14. If “No”, skip D-13, and answer D-14.                                Yes         No

D-13. If “Yes” above, what standard fee would you favor requiring the DWI offender to pay to the ADETS facility for the ADETS
      Service?                                                                                      $           .00
D-14. If “No” above, why do you not favor a change in the current $75.00 standard fee that the DWI offender is required to pay
      to the ADETS Facility for the ADETS Service?




Page 11 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
D-15. In your view, how much of a barrier to services access would an increase in the current $75.00 standard ADETS fee
      present to the DWI Offender? (Check one for each proposed fee amount)

a. Increase to $100 would be:               Extreme Barrier     High Barrier         Medium Barrier       Low Barrier             Not a Barrier

b. Increase to $125 would be:               Extreme Barrier     High Barrier         Medium Barrier       Low Barrier             Not a Barrier

c. Increase to $150 would be:               Extreme Barrier     High Barrier         Medium Barrier       Low Barrier             Not a Barrier


d. Increase to $175 would be:               Extreme Barrier     High Barrier         Medium Barrier       Low Barrier             Not a Barrier

e. Increase to $200 would be:               Extreme Barrier     High Barrier         Medium Barrier       Low Barrier             Not a Barrier

f. Increase to over $200 would be:          Extreme Barrier     High Barrier         Medium Barrier       Low Barrier             Not a Barrier



Section E:             Qualifications of Staff Instructors Providing ADETS Services
Provide the following information for each Substance Abuse Services staff member who provides ADETS Services in this
facility. (For more than four staff, attach additional pages as necessary)
                                  _______________________     _______________________     _______________________       _______________________
                                   Name of Staff Member # 1    Name of Staff Member # 2    Name of Staff Member # 3      Name of Staff Member # 4

E-1.   What is staff member’s           Degree & Major              Degree & Major              Degree & Major                Degree & Major
       educational degree(s)         HS or GED                   HS or GED                   HS or GED                     HS or GED
       attained and major            Associate ___________       Associate ___________       Associate ___________         Associate ___________
       field(s) of study?
                                     Bachelor   ___________      Bachelor   ___________      Bachelor   ___________        Bachelor   ___________
       (Check and list all
       that apply)                   Masters    ___________      Masters    ___________      Masters    ___________        Masters    ___________
                                     Doctorate ___________       Doctorate ___________       Doctorate ___________         Doctorate ___________
E-2.   What is staff member’s
       total number of years of
       supervised experience      Years:_________________     Years:_________________     Years:_________________       Years:_________________
       in providing substance
       abuse counseling?
E-3.   Is staff member
       registered with the
                                      Yes            No           Yes           No            Yes           No              Yes             No
       NCSA Professional
       Certification Board?


Page 12 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
Provide the following information for each Substance Abuse Services staff member who provides ADETS Services in this
facility. (For more than four staff, attach additional pages as necessary)
                                   _______________________      _______________________         _______________________         _______________________
                                    Name of Staff Member # 1     Name of Staff Member # 2        Name of Staff Member # 3        Name of Staff Member # 4

E-4.   List staff member’s      Certification or Credential     Certification or Credential     Certification or Credential       Certification or Credential
       current NCSAPCB           CSAC                             CSAC                            CSAC                             CSAC
       Certification(s) or Other CCAS                             CCAS                            CCAS                             CCAS
       Approved Credential(s).
                                 CCS                              CCS                             CCS                              CCS
       (Check all that apply)    CSARFD                           CSARFD                          CSARFD                           CSARFD
                                 Licensed MD                      Licensed MD                     Licensed MD                      Licensed MD
                                 Licensed Psychologist            Licensed Psychologist           Licensed Psychologist            Licensed Psychologist
                                 ASAM Diplomat                    ASAM Diplomat                   ASAM Diplomat                    ASAM Diplomat
E-5.   List languages (other     Spanish                          Spanish                         Spanish                          Spanish
       than English) that staff  American Sign Language           American Sign Language          American Sign Language           American Sign Language
       member speaks or
                                 Other: _______________           Other: _______________          Other: _______________           Other: _______________
       signs fluently.
       (Check all that apply)    Other: _______________           Other: _______________          Other: _______________           Other: _______________
E-6.   What do you recommend should be North Carolina’s minimum education requirements for a facility staff member to provide ADETS Services?
       (Check one)              HS or GED                Associate (in related field)    Bachelor (in related field)     Masters (in related field)
E-7.   What do you recommend should be North Carolina’s minimum substance abuse certification requirements for a facility staff member to provide ADETS
       Services? (Check one)                             None                            CSAC                            CCAS                       CSAPC

Section F:             DWI Substance Abuse Outpatient and Day Treatment/IOP Services
                            Shorter-Term (20 Hours over Minimum of 30 Days)
                            Longer-Term (40 Hours over Minimum of 60 Days)
                            Day Treatment/Intensive Outpatient Program (90 Hours over Minimum of 90 Days)

F-1.   Does your facility provide: (Check all that apply)
       DWI Substance Abuse Shorter-Term (20/30) Outpatient Treatment Services?                                    Yes                     No
       DWI Substance Abuse Longer-Term (40/60) Outpatient Treatment Services?                                     Yes                     No
       DWI Substance Abuse Day Treatment/IOP (90/90) Services?                                                    Yes                     No

If “Yes”, complete remainder of questions in Section F and Section G. If “No”, skip to Section H.




Page 13 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
F-2.   In your Shorter-Term (20/30) Outpatient Treatment, over the past 12 months, what is the estimated % of clients in each
       of the following three Substance Abuse diagnostic groups: (Three categories should add up to 100 % of your 20/30 clients)

No Substance-Related Diagnosis           Substance Abuse Diagnosis(es) Only       Substance Dependence Diagnosis(es)
                  %                                         %                                        %

                                                       Check    if Not Applicable (Facility does not provide 20/30)

(Questions do not pertain to other psychiatric disorders)

F-3.   In your Longer-Term (40/60) Outpatient Treatment over the past 12 months, what is the estimated % of clients in each
       of the following two Substance Abuse diagnostic groups: (Two categories should add up to 100 % of your 40/60 clients)
                                         Substance Abuse Diagnosis(es) Only       Substance Dependence Diagnosis(es)
                                                            %

                                                       Check    if Not Applicable (Facility does not provide 40/60)

(Questions do not pertain to other psychiatric disorders)

F-4.   In your Day Treatment/IOP (90/90) over the past 12 months, what is the estimated % of clients in each of the following
       two Substance Abuse diagnostic groups: (Two categories should add up to 100 % of your 90/90 clients)

                                         Substance Abuse Diagnosis(es) Only       Substance Dependence Diagnosis(es)
                                                            %                                        %
                                                       Check    if Not Applicable (Facility does not provide 90/90)

(Questions do not pertain to other psychiatric disorders)
F-5. DWI SA           Monday          Tuesday         Wednesday         Thursday            Friday           Saturday    Sunday
    Outpatient
    Treatment
     Schedule
    (List hours
     each day)




Page 14 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
F-6.   Generally, in the past 12 months, what is the number of clients in a DWI SA Outpatient Treatment group in your facility?

                                       (Complete all three categories)      Min. No.         Avg. No.              Max. No.

F-7.   What do you recommend should be the maximum number of persons treated in a DWI SA Outpatient Treatment group?
                                                                                       Max. Recom. No.


F-8.   Describe the DWI SA Outpatient Treatment Services treatment model and therapy utilized by your facility, including
       the name of any manualized or evidence-based treatment curriculum/curricula used.




F-9.   What is the estimated % of clients enrolled in DWI SA Outpatient Treatment in your facility that complete a Treatment
       Program within: (Include clients who complete treatment either at your facility or at another DWI facility)
                                                          1 year of enrollment?              %

                                                           2 years of enrollment?           % (Include all completed within 1 yr.)
           Unable to provide estimate from existing program records and tracking system

F-10.      Day      Monday          Tuesday        Wednesday             Thursday         Friday           Saturday              Sunday
   Treatment/
 IOP Services
     Schedule
    (List hours
     each day)


Page 15 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
F-11. Generally, over the past 12 months, what is the number of clients in a DWI SA Day Treatment/IOP group in your facility?
                                     (Complete all three categories)        Min. No.      Avg. No.       Max. No.


F-12. What do you recommend should be the maximum number of clients treated in a DWI SA Day Treatment/IOP group?
                                                                                              Max. Recom. No.

F-13. Describe the DWI SA Day Treatment Services treatment model and therapy utilized by your facility, including the name
      of any manualized or evidence-based treatment curriculum/curricula used.




F-14. What is the estimated % of clients enrolled in DWI SA Day Treatment/IOP in your facility that complete a Day
      Treatment/IOP within:   (Include clients who complete either at your facility or at another DWI facility)

                                                           1 year of enrollment?          %

                                                           2 years of enrollment?         % (Include all completed within 1 year)
           Unable to provide estimate from existing program records and tracking system

F-15. Does your facility charge the DWI offender a standard fee for the DWI SA Treatment Services?              Yes            No
      If “Yes”, answer F-16, and skip F-17. If “No”, skip F-16, and answer F-17.


F-16. If “Yes”, what are standard per client fees charged, by Level? Shorter-Term (20/30)                  $                 .00
                                       (Complete all that apply)        Longer-Term (40/60)                $                 .00
                                                                        Day Treatment/IOP(90/90))          $                 .00



Page 16 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
F-17. If “No”, what are the minimum, maximum, and average per client fees charged? (Complete all that apply)

                          Shorter-Term (20/30)                  $               .00          $               .00         $               .00
                                                                     Minimum                      Maximum                     Average
                          Longer-Term (40/60)                   $               .00          $               .00         $               .00
                                                                     Minimum                      Maximum                     Average
                          Day Treatment/IOP (90/90)             $               .00          $               .00         $               .00
                                                                     Minimum                      Maximum                     Average

F-18. List the estimated % of funding from each of your facility’s sources of reimbursement revenue received for the provision
      of Substance Abuse Treatment services to DWI Offenders in the past 12 months. (All sources combined should total 100%)

             % Client Self-Pay                            % Private Insurance                              % DMH/DD/SAS (IPRS System)

             % Medicaid                                   % Medicare                                       % Health Choice

              % CHAMPUS or CHAMPVA                        % Other Public Agency Contract                    % Private Contract

              % All Other Sources (Describe):__________________________________________________________________


F-19. In your experience, how much of a barrier to timely services access do your current fees for treatment present to the
      DWI Offender? (Check one)

            Extreme Barrier              High Barrier                  Medium Barrier              Low Barrier          Not a Barrier




Section G:         Qualifications of Staff Providing DWI SA Outpatient Treatment and Day Treatment
Provide the following information for each Substance Abuse Services staff member who provides DWI Substance Abuse
Outpatient Treatment and Day Treatment Services in this facility. (For more than four staff, attach additional pages as necessary)
                              _______________________      _______________________      _______________________     _______________________
                               Name of Staff Member # 1     Name of Staff Member # 2     Name of Staff Member # 3    Name of Staff Member # 4

Page 17 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
Provide the following information for each Substance Abuse Services staff member who provides DWI Substance Abuse
Outpatient Treatment and Day Treatment Services in this facility. (For more than four staff, attach additional pages as necessary)
                                   _______________________        _______________________        _______________________        _______________________
                                    Name of Staff Member # 1       Name of Staff Member # 2       Name of Staff Member # 3       Name of Staff Member # 4
G-1.   What is staff member’s            Degree & Major                 Degree & Major                 Degree & Major                 Degree & Major
       educational degree(s)          HS or GED                      HS or GED                      HS or GED                      HS or GED
       attained and major             Associate ___________          Associate ___________          Associate ___________          Associate ___________
       field(s) of study?
                                      Bachelor    ___________        Bachelor    ___________        Bachelor    ___________        Bachelor    ___________
       (Check and list all
       that apply)                    Masters     ___________        Masters     ___________        Masters     ___________        Masters     ___________
                                      Doctorate ___________          Doctorate ___________          Doctorate ___________          Doctorate ___________
G-2.   What is staff member’s
       total number of years of    Years:_________________        Years:_________________        Years:_________________        Years:_________________
       supervised experience
       in providing substance      Months:________________        Months:________________        Months:________________        Months:________________
       abuse counseling?
G-3.   Is staff member
       registered w/ the NCSA
                                       Yes            No              Yes            No              Yes            No              Yes            No
       Professional
       Certification Board?
G-4.   List staff member’s          Certification or Credential    Certification or Credential    Certification or Credential    Certification or Credential
       current NCSAPCB               CSAC                           CSAC                           CSAC                           CSAC
       Certification(s) or Other     CCAS                           CCAS                           CCAS                           CCAS
       Approved Credential(s).
                                     CCS                            CCS                            CCS                            CCS
       (Check    all that apply)     CSARFD                         CSARFD                         CSARFD                         CSARFD
                                     Licensed MD                    Licensed MD                    Licensed MD                    Licensed MD
                                     Licensed Psychologist          Licensed Psychologist          Licensed Psychologist          Licensed Psychologist
                                     ASAM Diplomat                  ASAM Diplomat                  ASAM Diplomat                  ASAM Diplomat
G-5.   List languages (other         Spanish                        Spanish                        Spanish                        Spanish
       than English) that staff      American Sign Language         American Sign Language         American Sign Language         American Sign Language
       member speaks or
       signs fluently.               Other: _______________         Other: _______________         Other: _______________         Other: _______________
       (Check all that apply)        Other: _______________         Other: _______________         Other: _______________         Other: _______________
G-6    What do you recommend should be North Carolina’s minimum education requirements for a facility staff member to provide Substance Abuse Outpatient
       Treatment or Day Treatment/IOP Services?
       (Check one)                      HS or GED             Associate (in related field)    Bachelor (in related field)      Masters (in related field)

G-7.   What do you recommend should be North Carolina’s minimum substance abuse certification requirements for a facility staff member to provide Substance
       Abuse Outpatient Treatment or Day Treatment/IOP Services?  (Check one)                 None                       CSAC                    CCAS




Page 18 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
Section H:         DWI Substance Abuse Services Quality Management and Program Performance Initiatives
                   and Measurement of Client Outcomes and Recidivism

H-1.   Describe your facility’s current initiatives, results, and planned future strategies in the measurement of client outcomes
       and recidivism to improve the effectiveness of services to DWI Offenders.

       (Use additional space as needed)




H-2.   Would your facility be interested in considering participation in the North Carolina Treatment Outcomes and Program
       Performance System (NC-TOPPS): (Check one box for each question)

             a. With the current manual TeleForm scanable forms provided by the Division?             Yes          No

             b. With the newly developed NC-TOPPS Web-Based Reporting Initiative?                     Yes          No




Page 19 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
Section I:           DWI Substance Abuse Services Issues and Concerns


I-1:   Describe issues and concerns related to the study of DWI Substance Abuse Services in North Carolina and to the
       Division’s efforts to improve services access for DWI offenders, to promote quality and effectiveness, and to
       ensure provider best practices and accountability.

       (Use additional space as needed)




Page 20 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04
Section J:                 Signatures of DWI Facility Staff
The following individual(s) affirm(s) that the information provided on this Survey is both accurate and complete:

_________________________________________________________________________________________________________________________________
J-1. REQUIRED - Facility Director or CEO                        (Printed Name and Signature)                                                    (Date Signed)
Printed Name, Signature, and Date Signed of Facility’s Administrative Director responsible for facility compliance with DMH/DD/SAS Licensure Rules



_________________________________________________________________________________________________________________________________
J-2. OPTIONAL – Facility Clinical Director (Qualified Substance Abuse Professional: QSAP)                   (Printed Name and Signature)             (Date Signed)
Printed Name, Signature, and Date Signed of Facility’s Clinical Director responsible for oversight of assessment, treatment, supervision, and clinical records and
practices

________________________________________________________________________________________________________________________________
J-3. OPTIONAL - NCSAPCB Certified Counselor (CSAC or CCAS) or ASAM Certified Physician                  (Printed Name and Signature)       (Date Signed)
Printed Name, Signature, and Date Signed of Individual Responsible for Provision of Facility’s DWI SA Assessment Reviews and DMH 508-R Form Signatures



*****************************************************************************************************************************************************************************************
                                       - Thank you for your assistance in completing this Survey -
                                                     Mail (preferred), deliver, e-mail, or fax to:
                                                      Daisy Adams, Quality Management Team,
                                                3004 Mail Service Center, Raleigh, NC 27699-3004, or
                                      Suite 634, Albemarle Building, 325 N. Salisbury Street, Raleigh, NC 27603.
                                 Telephone: 919-733-0696          Fax (919) 715-2772          Daisy.Adams@ncmail.net
                                       Survey is to be received by 5:00 p.m. on Friday, December 19, 2003

                                                           Address questions to:
                                  Jennifer Resnick, DWI Services QM Project Consultant at (919) 733-0696
                        Michael Eisen, Director of DWI Services, at (919) 733-0566, or Michael.Eisen@ncmail.net, or
                 Spencer Clark, Director of Operations and Clinical Services, at (919) 733-4670, or Spencer.Clark@ncmail.net.



                                                                                                                             Provider Survey of Qualified SA Staff o.doc.12/11/03


Page 21 - Joint Legislative Oversight Committee on MH, DD, and SAS: DWI Facility QM Survey of SAS to DWI Offenders - SFY 03-04

								
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